Professional Documents
Culture Documents
TABLE OF CONTENTS
1. 2. 3.
KEYHEALTH MEDICAL SCHEME INTRODUCTION GLOSSARY AND ABBREVIATIONS BENEFIT STRUCTURE AND CONTRIBUTIONS 3.1 3.2 3.3 3.4 3.5 PLATINUM OPTION GOLD OPTION SILVER OPTION EQUILIBRIUM OPTION ESSENCE OPTION
7 11 17 19 27 35 41 47 53 54 57 59 60 61 63 65
4.
MEMBERSHIP 4.1 4.2 4.3 4.4 4.5 4.6 MEMBERSHIP APPLICATION UNDERWRITING MEMBERSHIP CHANGES RETIREMENT / DEATH OF PRINCIPAL MEMBER CONTRIBUTIONS TERMINATION OF MEMBERSHIP
5.
6.
MEDICATION 6.1 6.2 6.3 6.4 PRESCRIBED ACUTE MEDICATION MAXIMUM MEDICAL SCHEME PRICE (MMAP) OVER-THE-COUNTER MEDICATION REGISTRATION FOR CHRONIC CONDITIONS AND PRESCRIBED CHRONIC MEDICATION 6.5 THE CONDITION MEDICINE LIST (CML) 6.6 REFERENCE PRICE 6.7 OTHER CHRONIC CONDITIONS (PLATINUM OPTION) 6.8 BIOLOGICAL MEDICINE 6.9 DSP PHARMACIES 6.10 CHRONIC MEDICATION ON TRAVELLING ABROAD
71 72 73 73 74 74 75 77 78 80 81 83 84 85 87 87 87 88 91 92 92 94 97 101 105
7.
HOSPITALISATION AND MANAGED HEALTHCARE 7.1 7.2 7.3 7.4 7.5 7.6 AUTHORISATION OF HOSPITAL ADMISSIONS DISEASE / CASE MANAGEMENT MATERNITY PROGRAMME MEDICAL APPLIANCES PROSTHETICS OUTPATIENTS
8.
DENTAL BENEFITS 8.1 DENIS CONTACT DETAILS 8.2 GENERAL DENTAL INFORMATION 8.3 HOSPITALISATION BENEFITS
9.
OPTICAL BENEFITS
12. CLAIMS 12.1 CLAIMS PROCEDURES 12.2 MOTOR VEHICLE ACCIDENT (MVA) 12.3 INJURY ON DUTY (IOD) 12.4 CLAIMS STATEMENT 12.5 TRAVELLING ABROAD 13. MEDICAL SAVINGS ACCOUNT (MSA) 14. LIST OF EXCLUSIONS 15. HEALTH BOOSTER 16. FRAUD / UNETHICAL CONDUCT 17. ELECTRONIC COMMUNICATION 17.1 VIA THE INTERNET 17.2 VIA E-MAIL (WEBMAIL) 17.3 VIA SMS 18. IMPORTANT CONTACT INFORMATION
111 112 115 115 115 116 119 123 131 135 139 140 142 142 145
08
09
012
Agreed tariff: A tariff as agreed upon between the Scheme and certain service providers. Angiogram: An angiogram is an X-ray examination where a special dye and camera (fluoroscopy) are employed to take pictures of the blood flow in arteries. Beneficiary: A Principal Member of the Scheme or a person registered as a Dependant of a Principal Member. Case management: The application of Rules, clinical protocols and medical procedures for the treatment of specific conditions. Chronic Disease List (CDL): A list of chronic illness conditions that are covered by the Scheme in terms of applicable legislation. Chronic medication: Prescribed medication continuously used for more than three (3) months for chronic conditions contained in the Schemes PMB CDL (Category A, 26 conditions all options) and/or the Other Conditions (Category B, 29 conditions Platinum option only).
013
Conservative dentistry: Basic dental services, such as fillings, extractions and oral hygiene. Co-payment: The portion of the amount due that a Member must pay directly to the service provider involved and in accordance with the latest Scheme Rules. CT and MRI scans: Specialised, high definition external scanning methods for internal bodily examinations. Day-to-day benefit: On the Platinum, Gold, Silver and Equilibrium options - an annual, combined, non-transferable, out-of-hospital limit which may be utilised (with due allowance for certain limitations) by any of the registered Beneficiaries in respect of products and services as stated in the latest version of the different benefit structures. Dental management: A cost and quality Dental Management Programme provided and managed by DENIS (Dental Information Systems). Designated Service Provider (DSP): A healthcare provider or group of providers selected by the Scheme as the preferred provider(s) to supply its Members with diagnosis, treatment and health products at specific negotiated tariffs. Emergency: An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or intervention. If the treatment/intervention is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death. Generic medicine: Medicine with the same active ingredients and medicinal effect as the original brand name counterpart, but usually lower in price.
014
Health Booster: An additional benefit for preventive care available to Beneficiaries of the Scheme at no extra cost. MMAP: Maximum Medical Aid Price - MediKredits MMAP is a guideline to determine the maximum price that medical schemes will reimburse for specific pharmaceutical products. Medical Scheme Tariff (MST): The maximum tariff the Scheme is willing to pay for services rendered by healthcare service providers. NAPPI code: National Pharmaceutical Product Interface codification used for unique medication identification. Oncology: The treatment of cancer. Optical management: A cost and quality Optical Management Programme provided by Opticlear. PET scan: A Positron Emission Tomography scan - an imaging study using a very small dose of a radioactive tracer that helps to distinguish cancer from benign tissue to assist in assessing the response of cancer to therapy. Physical trauma: A severe bodily injury due to violence or an accident, e.g. a gunshot, stabbing, a fracture or a motor vehicle accident, causing serious and life-threatening physical injury, potentially resulting in secondary complications such as shock, respiratory failure or death. This includes penetrating, perforating and blunt force trauma. Platinum option: The day-to-day benefits on the Platinum option comprise the following: - Routine portion - Self-funding gap - Threshold
015
When the routine portion has been depleted, the Member is responsible for the payment of day-to-day expenses, and submits proof of cash payments (copy of account and receipt) to the Scheme, as these claims accumulate to the total of the self-funding gap. The self-funding gap will accumulate according to MST rates. Threshold: Once the self-funding gap has been bridged, the Member will have access to further benefits. (See Chapter 3: Benefit Structure and Contributions, for details.) Over-the-counter medication is included in the self-funding gap and threshold with a sub-limit. (See Chapter 3: Benefit Structure and Contributions, for details.) Special Dependant: The immediate family of a Principal Member and/or his Spouse/Partner (i.e. parents, in-laws, grand children, brothers and/or sisters). In the case of grandchildren, the relevant legal documentation is a membership requirement.
020
MST ()
BENEFIT
R36 000
SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS ONCOLOGY RADIOLOGY
Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined in- and out-of-hospital. Sublimit of R15 000 pfpa on out-of-hospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Unlimited. Pre-authorisation compulsory and subject to case management.
Unlimited. Pre-authorisation compulsory and subject to case management. Unlimited. Pre-authorisation compulsory and subject to case management. Pre-authorisation compulsory for specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.) R15 000 Pfpa. R1 000 co-payment per scan (in- or outof-hospital), excluding confirmed PMBs. Unlimited. Unlimited number of scans. Limited to R11 000 per scan.
021
MST ()
100% 100% 80%
BENEFIT
R55 000
OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy.
MST ()
100%
BENEFIT
Limited to: Principal Member: R6 550 p.a. Adult Dependant: R6 350 p.a. Child Dependant: R1 550 p.a.
90% 90% Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES 100% R1 800 R125 100% R3 200
Frames Lenses Eye test Contact lenses Refractive surgery PHYSIOTHERAPY PATHOLOGY
R950
100% 80%
Self-funding gap : (MST) PM: R2 290 AD: R2 040 CD: R750 Threshold: co-payment on all services in threshold zone. Prescribed medicine: sublimit in threshold zone of PM: R5 400 AD: R2 450 CD: R1 200 Pfpa sublimit. Subject to day-to-day and threshold. Pbpa; one (1) pair per year. Subject to overthe-counter medicine sublimit. Pbp2a total optical benefit. Subject to day-to-day benefit, threshold and Optical Management. Benefit confirmation compulsory. Per frame, one (1) frame pbp2a. Subject to overall optical benefit. One (1) pair pbp2a. Subject to overall optical benefit. One (1) test pbp2a. Subject to overall optical benefit. Pbpa. Pbp2a. Pre-authorisation compulsory. Pfpa sublimit. Subject to day-to-day benefit and threshold. Pfpa sublimit. Subject to day-to-day benefit and threshold. (Co-payment payable directly to the service provider involved.)
022
OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry
MST ()
BENEFIT
Two (2) check-ups pbpa. One (1) pbp3a. (Additional benefit may be granted where specialised dental treatment planning / follow-up is required.) Two (2) scale and polish treatments pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols. One (1) set (an upper and a lower jaw) pbp4a. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. Two (2) frames (an upper and a lower jaw) pbp5a. DENIS pre-authorisation compulsory. A treatment plan and X-rays may be requested. One (1) per tooth pbp5a. Pbpa limitation on cost of implant components. DENIS pre-authorisation compulsory. DENIS pre-authorisation compulsory. Cases will be clinically assessed using orthodontic indices. Where function is impaired. Not for cosmetic reasons; laboratory costs also excluded. Only one (1) Beneficiary per family may commence treatment per calendar year. Limited to Beneficiaries younger than 18 years. DENIS pre-authorisation compulsory. Limited to conservative, non-surgical therapy (root planing) only and will be applied to Beneficiaries registered on the Perio Programme.
Oral hygiene Fillings Root canal treatment and tooth extractions Plastic dentures Specialised dentistry Partial metal frame dentures Crowns and bridges
80% 80%
Implants Orthodontics
80% 80%
R2 700
Periodontics
80%
023
OUT-OF-HOSPITAL BENEFIT
[DENTISTRY Continued] Maxillo-Facial and Oral surgery Surgery in dental chair
MST ()
BENEFIT
Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% DENIS pre-authorisation not required. Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical intervention/treatment. Claims for oral pathology procedures (cysts, biopsies and tumour removals) only covered if supported by a laboratory report confirming diagnosis. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% R1 000 co-payment per hospital admission. Extensive dental treatment for very young Child Dependants. Removal of impacted wisdom teeth. DENIS pre-authorisation compulsory. DENIS pre-authorisation not required.
Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia)
100%
Laughing gas in dental 100% rooms DENIS pre-authorisation compulsory. IV conscious sedation in 100% Limited to extensive dental treatment. dental rooms PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
024
90%
HIV/AIDS
100%
R35 000
100%
MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). HEARING AIDS Hearing aids Maintenance (batteries included) ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)
100%
No authorisation required. Pfp4a. Pbpa. Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).
MONTHLY CONTRIBUTION
Monthly contribution Principal Member R4 061 Adult Dependant R2 846 Child Dependant R855
025
NOTES:
028
MST ()
BENEFIT
R24 500
SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS
Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined benefit; in- and out-ofhospital. Sublimit of R10 000 pfpa on out-ofhospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only. Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management. Pre-authorisation compulsory for specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (MSA / day-to-day benefits will then apply.) Pfpa. R1 000 co-payment per scan (in- or outof-hospital), excluding confirmed PMBs. Unlimited. Unlimited number of scans. Limited to R11 000 per scan.
100%
ONCOLOGY RADIOLOGY
100% 100%
R220 000
R10 000
029
MST ()
100% 100%
BENEFIT
R22 500
OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy. Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES
MST ()
100%
BENEFIT
Annual Medical Savings Account (MSA): Principal Member: R3 096 p.a. Adult Dependant: R2 088 p.a. Child Dependant: R600 p.a. Additional benefits limited to: Principal Member: R2 540 p.a. Adult Dependant: R1 890 p.a. Child Dependant: R600 p.a.
100%
R1 200 R105
100%
R1 900
Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY 60%
R600
R900
Pfpa sublimit. Subject to MSA / day-to-day benefit. Pbpa; one (1) pair per year. Subject to overthe-counter medicine sublimit. Pbp2a total optical benefit. Subject to MSA / day-to-day benefit and Optical Management. Benefit confirmation compulsory. Per frame, one (1) frame pbp2a. Subject to overall optical benefit. One (1) pair pbp2a. Subject to overall optical benefit. One (1) test pbp2a. Subject to overall optical benefit. Pbpa. Subject to overall optical benefit. Pre-authorisation compulsory - subject to overall optical benefit. Subject to MSA / day-to-day benefit. (Copayment payable directly to the service provider involved.)
030
OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry
MST ()
BENEFIT
Two (2) check-ups pbpa. One (1) pbp3a. (Additional benefit may be granted where specialised dental treatment planning / follow-up is required.) Two (2) scale and polish treatments pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols.
Root canal treatment and tooth extractions Plastic dentures Specialised dentistry Partial metal frame dentures Crowns and bridges
100% 100% One (1) set (an upper and a lower jaw) pbp4a. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. One (1) partial metal frame (an upper or a lower jaw) pbp5a. DENIS pre-authorisation compulsory. A treatment plan and X-rays may be requested. One (1) per tooth pbp5a. No benefit. Subject to MSA. DENIS pre-authorisation compulsory. Cases will be clinically assessed using orthodontic indices. Where function is impaired. Not for cosmetic reasons; laboratory costs also excluded. Only one (1) Beneficiary per family may commence treatment per calendar year. Limited to Beneficiaries younger than 18 years. DENIS pre-authorisation compulsory. Limited to conservative, non-surgical therapy (root planing) only and will be applied to Beneficiaries registered on the Perio Programme.
80% 80%
Implants Orthodontics
80%
Periodontics
80%
031
OUT-OF-HOSPITAL BENEFIT
[DENTISTRY Continued] Maxillo-Facial and Oral surgery Surgery in dental chair
MST ()
BENEFIT
100%
Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia)
100%
Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. DENIS pre-authorisation not required. Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical intervention/treatment. Claims for oral pathology procedures (cysts, biopsies and tumour removals) only covered if supported by a laboratory report confirming diagnosis. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
100%
R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Extensive dental treatment for very young Child Dependants. Removal of impacted wisdom teeth.
DENIS pre-authorisation not required. Laughing gas in dental 100% rooms DENIS pre-authorisation compulsory. IV conscious sedation in 100% Limited to extensive dental treatment. dental rooms PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
032
100%
R29 000
100%
MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). HEARING AIDS Hearing aids Maintenance (batteries included) ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)
100% R5 500
No authorisation required. Pfp4a. Pbpa. Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).
MONTHLY CONTRIBUTION
Principal Member Monthly contribution R2 326 Monthly savings R258 Total monthly contribution R2 584 Adult Dependant R1 571 R174 R1 745 Child Dependant R455 R50 R505
033
NOTES:
036
MST ()
BENEFIT
Private Hospitals State hospitals 100% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R165
R12 000
SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound Care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS
100%
ONCOLOGY
100%
R106 000
Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management.
037
MST ()
100%
BENEFIT
MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External)
R10 000
100% 100%
OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy. Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY
MST ()
100%
BENEFIT
Limited to: Principal Member: R4 660 p.a. Adult Dependant: R3 390 p.a. Child Dependant: R940 p.a. 2pfpa - additional General Practitioner consultations after depletion of available dayto-day benefit.
100%
R980 R85
Pfpa sublimit. Subject to day-to-day benefit. Pbpa; one (1) pair per year. Subject to overthe-counter medicine sublimit. Pbp2a total optical benefit. Subject to dayto-day benefit and Optical Management. Benefit confirmation compulsory. Per frame, one (1) frame pbp2a. Subject to overall optical benefit. One (1) pair single vision lenses pbp2a. Subject to overall optical benefit. One (1) test pbp2a. Subject to overall optical benefit. Pbpa. Subject to overall optical benefit. No benefit. Subject to day-to-day benefit. (Co-payment payable directly to the service provider involved.)
100%
R950 R320
R420 60%
038
OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry
MST ()
BENEFIT
Consultations X-rays: Intra-oral X-rays: Extra-oral Oral hygiene Fillings Root canal treatment and tooth extractions Plastic dentures Specialised dentistry Maxillo-Facial and Oral surgery Surgery in dental chair
Two (2) check-ups pbpa. One (1) pbp3a. Two (2) scale and polish treatments pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols.
One (1) set (an upper and a lower jaw) pbp4a. No benefit Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
100%
DENIS pre-authorisation not required. Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical intervention / treatment. Claims for oral pathology procedures (cysts, biopsies and tumour removals) only covered if supported by a laboratory report confirming diagnosis. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia) Laughing gas in dental rooms
100%
100%
R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.
100%
IV conscious sedation in 100% DENIS pre-authorisation compulsory. dental rooms Limited to extensive dental treatment. PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
039
100%
R23 500
100%
MEDICAL APPLIANCES Wheelchairs, orthopedic appliances, hearing aids and incontinence equipment (including contraceptive devices and maintenance of hearing aids). ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)
100% R4 500
100%
Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).
MONTHLY CONTRIBUTION
Monthly contribution Principal Member R1 937 Adult Dependant R1 041 Child Dependant R402
042
MST ()
BENEFIT
Private Hospitals State hospitals 150% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R335
R12 000
SUB-ACUTE FACILITIES & WOUND CARE Wound care, hospice, private nursing, rehabilitation and stepdown facilities. BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS
100%
100% 100%
Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only.
100%
ONCOLOGY
100%
R95 000
Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management.
043
MST ()
100%
BENEFIT
MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External)
R10 000
100% 100%
OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy. Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY
MST ()
100%
BENEFIT
Annual Medical Savings Account (MSA): Principal Member: R1 116 p.a. Adult Dependant: R672 p.a. Child Dependant: R336 p.a. Additional benefits limited to: Principal Member: R1 590 p.a. Adult Dependant: R890 p.a. Child Dependant: R480 p.a. R75 Pbpa; one (1) pair per year. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. No benefit. Subject to MSA. Subject to MSA / day-to-day benefit.
100%
100%
044
OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry
MST ()
BENEFIT
Consultations
100%
One (1) check-up pbpa. Three (3) specific (emergency) consultations pbpa. Four (4) peri-apical radiographs pbpa. One (1) pbp3a. One (1) scale and polish treatment pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols. No benefit. Subject to MSA. No benefit. Subject to MSA. No benefit. Subject to MSA. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Tooth extractions Root canal treatment Plastic and metal frame dentures Specialised dentistry Maxillo-Facial and Oral surgery Surgery in dental chair Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia) Laughing gas in dental rooms
100%
100% 100%
DENIS pre-authorisation not required. Wisdom teeth removal only. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
100%
R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.
100%
IV conscious sedation in 100% DENIS pre-authorisation compulsory. dental rooms Limited to extensive dental treatment. PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
045
100%
R21 000
100%
MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). Hearing aids and maintenance ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)
100% R4 500
No benefit. Subject to MSA. 100% Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).
MONTHLY CONTRIBUTION
Monthly contribution Monthly savings Total monthly contribution Principal Member R1 070 R 93 R1 163 Adult Dependant R645 R56 R701 Child Dependant R327 R28 R355
048
MST ()
BENEFIT
Private Hospitals State hospitals 100% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R275
R12 000 SUB-ACUTE FACILITIES & WOUND CARE Wound care, hospice, private nursing, rehabilitation and stepdown facilities. BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS 100%
100% 100%
Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only.
100%
ONCOLOGY
100%
R95 000
Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management.
049
MST ()
100%
BENEFIT
MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External)
R 10 000
100% 100%
OUT-OF-HOSPITAL BENEFIT
Over-the-counter medication Over-the-counter reading glasses PATHOLOGY OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery
MST ()
100%
BENEFIT
R445 R75
050
OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry
MST ()
BENEFIT
Consultations
100%
One (1) check-up pbpa. Three (3) specific (emergency) consultations pbpa. Four (4) peri-apical radiographs pbpa. One (1) pbp3a. One (1) scale and polish treatment pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols. No benefit. No benefit. No benefit. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Tooth extractions Root canal treatment Plastic and metal frame dentures Specialised dentistry Maxillo-Facial and Oral surgery Surgery in dental chair Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia) Laughing gas in dental rooms
100%
100% 100%
DENIS pre-authorisation not required. Wisdom teeth removal only. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
100%
R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.
100%
IV conscious sedation in 100% DENIS pre-authorisation compulsory. dental rooms Limited to extensive dental treatment. PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
051
100%
R21 000
100%
MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). Hearing aids and maintenance ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)
100% R4 500
No benefit. 100% Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).
MONTHLY CONTRIBUTION
Monthly contribution Principal Member R899 Adult Dependant R543 Child Dependant R275
04 | MEMBERSHIP
054
WHO
Principal Member Biological baby
WHAT
Copy of ID. Membership certificate from previous medical scheme (if applicable). Copy of ID. Copy of marriage certificate / proof of marriage. Membership certificate from previous medical scheme (if applicable). Copy of birth certificate or proof of birth from hospital/ clinic. Note: babies must be registered within 90 days of birth. Copy of ID. Membership certificate from previous medical scheme (if applicable). Copy of ID. Proof of full-time studies (if applicable). Affidavit, stating that child is not self-supporting. Membership certificate from previous medical scheme (if applicable). Copy of ID. Debit order authorisation (contributions; if applicable). Copy of latest bank statement or affidavit of financial means. Copy of ID. Copy of death certificate. Debit order authorisation (contributions; if applicable). Copy of latest bank statement or affidavit of financial means.
Husband/Wife
Continuation of membership
Widow(er)
055
WHO
Disabled Dependant Legally adopted child Child born before/out of wedlock (if surname differs) Stepchild Special Dependant
WHAT
Copy of ID. Copy of death certificate of late parent(s). Debit order authorisation (contributions; if applicable). Copy of latest bank statement or affidavit of financial means. Official documents confirming continuation of membership. Copy of ID. Proof of disability from Medical Practitioner. Copy of birth certificate. Copy of final adoption order. Copy of ID. Affidavit, confirming co-habitation. Membership certificate from previous medical scheme (if applicable). Copy of birth certificate or proof of birth from hospital/ clinic. Affidavit that child is the biological child of the Principal Member. Note: babies must be registered within 90 days of birth. Copy of birth certificate. Affidavit that child is the biological child of the Principal Members Spouse/Partner. Membership certificate from previous medical scheme (if applicable). Copy of ID. Proof of income, or Affidavit stating financial dependency on the Principal Member. Membership certificate from previous medical scheme (if applicable).
Orphan
Members Partner
Please note: Where applicable, always complete the Medical Details section of the application form in full and correctly.
056
Individuals of the Principal Members family / household / family group qualifying for registration as Dependants:
A Spouse to whom the Principal Member is married in terms of any recognised South African law or custom. A recognised Life Partner of the Principal Member, irrespective of sex. The Principal Members own, step- or legally adopted child who is not receiving a regular income of more than the current Social Pension. Anyone of the Principal Members immediate family (i.e. parents, in-laws, grandchildren, brothers or sisters) for whom the Principal Member is responsible to provide financial support is regarded as a Special Dependant. Please note: None of the above should be an existing beneficiary of any registered medical scheme.
057
Insurability:
Proof of health is provided when the Principal Member completes the Medical Details section on the application form and signs the form (where applicable). According to legislation, the Scheme is entitled to request a health certificate for any applicant (Principal Member and/or Dependant), where applicable. Please note: It is important to disclose each applicants full medical history as this will prevent possible rejections and/or further actions because of non-disclosure.
4.2|UNDERWRITING
If a Principal Member and/or Dependant suffers from a specific illness, the Scheme has the right to exclude benefits for this specific condition for a period of up to twelve (12) months. Subject to the Rules, the Scheme may impose upon a person in respect of whom an application is made for membership or admission as a Dependant, and who was not a beneficiary of a medical scheme for a period of at least ninety (90) days preceding the date of application: - a General Waiting Period of up to three (3) months, including PMB conditions; and - a Condition-specific Waiting Period of up to twelve (12) months, including PMB conditions. The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a Dependant, and who was previously a beneficiary of a medical scheme for a continuous period of up to twenty-four (24) months, terminating less than ninety (90) days immediately prior to the date of application: - a Condition-specific Waiting Period of up to twelve (12) months, except in respect of any treatment or diagnostic procedures covered within PMB conditions; and - in respect of any person contemplated, where the previous medical scheme had imposed a General or Condition-specific Waiting Period, and such waiting period had not expired at the time of termination, a General or Condition-specific Waiting Period for the unexpired duration of such waiting period imposed by the former medical scheme.
058
The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a Dependant, and who was previously a beneficiary of a medical scheme for a continuous period of more than twenty-four (24) months, terminating less than ninety (90) days immediately prior to the date of application: - a General Waiting Period of up to three (3) months, except in respect of any treatment or diagnostic procedures covered within PMB conditions.
Non-disclosure consequences:
If found that false information has been submitted or that any relevant information has deliberately been omitted on an application, the Scheme may correct this in terms of its Rules, which may include re-underwriting or termination of membership.
Membership cards:
Principal Members with one or more Dependant are provided with two (2) membership cards. Principal Members without Dependants are provided with one (1) membership card.
059
A membership card, presented on request to the service provider (e.g. a General Practitioner), is proof that the holder is a registered Scheme member. A membership card remains the property of the Scheme and must be destroyed when membership is terminated. A membership card may never be used by anyone other than the Principal Member or his/her registered Dependants. Keep membership cards in a safe place.
060
A Member joining the Scheme has the right to change benefit option within the first three (3) months:
The change will be effective from the date of joining, with backdated correction of membership fees and claims submitted.
Inform the Scheme within thirty (30) days in the event of any of the following changes to membership details:
Registration of new dependant(s). Dependant(s) no longer qualifying for membership. Contact details (postal address, telephone number, fax number, cell number and e-mail address). Banking details (include the latest bank statement or an official letter from the bank), indicating whether the change is applicable to claims refund or contribution deduction.
061
4.5| CONTRIBUTIONS
Date of payment:
Contributions are payable in arrears for Local Authority members and in advance for all other Members. - Contributions, payable in arrears, must be paid by the end of each month: Example: Contributions for January must be received by 31 January. - Contributions, payable in advance, must be paid by the 7th of each month: Example: Contributions for January must be received by 7 January.
062
Adjustment to contributions:
If contributions are adjusted due to the registration of an additional Dependant, the adjusted fees are payable as from the first day of the month of the new registration. Please note: Benefits for such a Dependant will apply from the date of membership, provided that all conditions have been met. If contributions are adjusted due to the registration of a newborn baby Dependant, the adjusted fees are payable as from the first day of the month following the babys date of birth. Please note: Benefits for such a Dependant will apply from the date of birth, provided that all conditions have been met.
Method of payment:
Contribution payments can only be made into the following bank account: Bank Name of Account Holder Account Number Reference Number | | | | ABSA KeyHealth Medical Scheme 6 000 000 12 Membership Number
Please do NOT mail cash or cheques. The Scheme does NOT accept any responsibility if cash or cheques get lost in the mail. It is very important that Members use their membership number as reference for ALL deposits made to / correspondence with the Scheme. Please fax proof of payment to 0860 111 390, attention: Scheme Finance.
063
Certificate of membership:
On termination of membership, the Scheme will furnish a certificate of membership.
Re-instatement of membership:
A Member may apply for re-instatement of membership within thirty (30) days of the termination date. Such an application must be accompanied by a Declaration of Health to determine any underwriting. A Member terminated due to outstanding debt may apply for re-instatement within thirty (30) days from the date of notification of termination, provided that all outstanding debts are settled. Such application must be accompanied by a Declaration of Health to determine any underwriting.
066
PMB Category
Brain and nervous system Eye Ear, nose and throat Respiratory system Heart and vascular system (blood vessels) Gastro-intestinal system Liver, pancreas and spleen Musculoskeletal system (muscles and bones) Skin and breast Endocrine, metabolic and nutritional system Urinary and male genital system
Example
Stroke Glaucoma Cancer of oral cavity, pharynx, nose, ear and larynx Pneumonia Heart attack Appendicitis Gallstones Fracture of the hip Treatable breast cancer Disorders of the parathyroid gland End-stage kidney disease
067
PMB Category
Female reproductive system Pregnancy and childbirth Haematological, infectious and miscellaneous systemic conditions Mental conditions
Example
Cancer of the cervix, ovaries and uterus Antenatal and obstetric care requiring hospitalisation, including delivery HIV/Aids and TB Schizophrenia
The Chronic Disease List (CDL) specifies the 25 chronic conditions that are covered (see below). Please note: PMBs are not influenced by Scheme exclusions.
ICD-10 codes:
A PMB condition can only be correctly identified by indicating the appropriate ICD-10 code. It is thus of the utmost importance that the correct ICD-10 codes are used in order to ensure that PMB-related services are paid from the appropriate benefits or paid at all. The correct ICD-10 codes must also appear on the relevant medicine prescriptions and referral notes to other healthcare service providers. In accordance with the Act, healthcare service providers are not allowed to retrospectively change ICD-10 codes, which have already been submitted to the Scheme. In cases where such codes are changed by service providers, the Scheme will not re-process the affected claims.
Emergency:
An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or intervention. If the treatment/ intervention is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.
068
Subject to application and approval, the Scheme will pay 100% of MST in respect of any services which are voluntarily obtained by a Beneficiary from a service provider other than the DSP for a PMB condition. Subject to application and approval, any services in respect of PMBs which are involuntarily obtained by the Beneficiary from a service provider other than the DSP will be covered in full. (*) , A Beneficiary will be deemed to have involuntary obtained a service from provider other than the DSP if: , - the service was not available from the DSP or would not be provided without unreasonable delay; - immediate medical or surgical treatment for a PMB condition was required under circumstances or at locations which reasonably precluded the Beneficiary from obtaining such treatment from a DSP; or - there was no DSP within reasonable proximity of the Beneficiarys ordinary place of business or personal residence. Except in the case of an emergency medical condition, pre-authorisation shall be obtained by a Member prior to involuntary obtaining a service from a provider other than a DSP in terms of this paragraph to enable the Scheme to confirm that the circumstances contemplated in paragraph (*) above are applicable.
DSPs for PMBs: Any service falling within the PMBs and rendered by the Schemes Designated Service Provider (DSP) will be covered in full. The Scheme has appointed the following DSPs in respect of hospitalisation:
The National Hospital Network (NHN). The State Hospitals (Gauteng, Free State and Western Cape) as the DSP for any major medical services which fall within PMBs. In the absence of any formal agreement, any other hospital will be regarded as a DSP . CareCross Specialist Network. (This network will also be applicable to out-of-hospital, PMB related services. Details of Specialists on the network may be obtained from the Authorisation Call Centre on 0860 671 060. A full list will also be available at www.keyhealthmedical.co.za.)
069
NOTES:
06 | MEDICATION
072
If only a prescription for medication is received upon discharge from the hospital, the medication thus obtained will be paid from the day-to-day benefit and does not qualify as medication on discharge.
073
074
075
The CML does not contain all medication that may possibly be required to treat a patients condition, as some medication requires a specific authorisation. This authorisation will be limited to a specific period, depending on the prescription and the motivation from the treating Doctor/Specialist. Please refer to MediKredit on the KeyHealth website on www.keyhealthmedical.co.za for chronic conditions, updated products and prices, as well as possible alternatives at lower prices. This search facility also indicates at a product level whether co-payments apply.
Formulary medicine:
According to legislated therapeutic algorithms (treatment plans), the Scheme makes use of medicine formularies (medicine lists) for chronic medication by focusing on the management of cost and ensuring accessibility and appropriate care to all Beneficiaries. These formularies are approved lists of medication for each of the 26 chronic conditions covered by the Scheme and do not compromise the quality of healthcare the Beneficiary receives. These medicines are included with the CML and are available to all patients with the specified condition to which no reference price applies, provided they are claimed in appropriate quantities.
Non-formulary medicine:
Reference pricing may be applied to non-formulary medicine for both PMB CDL and non-PMB CDL conditions, in accordance with the benefit selected by the Beneficiary (refer to details discussed under Reference Price below).
076
where applicable, that is less expensive and does not incur any additional out-of-pocket costs. However, if the Beneficiary chooses to remain on the existing, more expensive product when appropriate alternatives are available, a co-payment will apply. Reference price is reviewed once a year. This review process considers all the new medicine entries during the year, medicine discontinuations, new enhancements, clinical literature, licensed indications, price changes, generic influence, patent expiry etc. Please refer to MediKredit on the KeyHealth website at www.keyhealthmedical.co.za to determine the reference price of the medicine currently used. If the medicine displayed on the screen is above reference price, the Beneficiary will then be required to pay a co-payment at the point of dispensing. The reference price is based on the cost of medicine from a similar drug class listed on the formulary to which no reference price applies. The Beneficiary is required to pay the difference between the cost of the medicine and the reference price of the formulary medicine at the point of dispensing. Please note: If certain medicine is still not authorised after intervention by the Doctor/Specialist, or the condition being treated does not fall under Table 1 or 2, the Beneficiary can obtain the medicine from a local pharmacy or a dispensing Doctor and claim it against the available day-to-day benefits, if applicable. TABLE 1 (CATEGORY A): PRESCRIBED MINIMUM BENEFIT (PMB) CHRONIC DISEASE LIST (CDL) (ALL OPTIONS)
077
Chronic medication for PMB conditions indicated with (#) (only for severe life threatening cases and motivated by the appropriate Specialist) will be paid at 100% of the cost at a DSP pharmacy. 10% co-payment on chronic medication for non-PMB conditions. Please note: Additional co-payments may be incurred if the price of products used is higher than the reference price/MMAP. Managed Health Care protocols apply to all conditions.
078
6.8.2| PMB (not on Algorithm), e.g. rheumatoid arthritis, Crohns disease and ulcerative colitis:
Applicable to the Platinum option only; 10% co-payment when medication is obtained from a non-DSP; Payable from the chronic benefit and then from risk.
079
Once the annual chronic limit has been exceeded, the provider must contact MediKredit for DTP authorisation. Thereafter, rules and co-payments apply as per 6.8.3 above.
6.8.6| Oncology:
Medication for treatment will be considered in accordance with the South African Oncology Consortium (SAOC) guidelines and protocols: - Tier 3 30% co-payment. Platinum option only. - Tier 2 (State facilities) no co-payment. All options. - Tier 2 (not in State facilities) Platinum option no co-payment. Other options - co-payment. - Tier 1 All options - no co-payment.
080
SUPPLIER
Chronic Medicine Dispensary Clicks Pharmacy Direct Medicines clicks.directmedicines@dirmed.co.za Dis-Chem Medipost keyhealth@medipost.co.za MediRite Pharmacies mediritechronic@shoprite.co.za
WEBSITE
www.chronicmedicine.com www.clicks.co.za www.directmedicines.co.za www.dischem.co.za www.medipost.co.za www.medirite.co.za
TELEPHONE
0860 633 420 0860 254 257 0861 444 405 0800 201 170 012 426 4075 012 426 4076 0800 010 709
Please note: HIV/Aids medicine must be obtained from First Care Courier Pharmacy. Should Members choose to obtain this medicine from any other pharmacy; the Scheme will not be responsible for the payment thereof.
081
084
085
Should Members receive accounts requesting additional payments for hospitalisation, kindly contact the Client Service Centre on 0860 671 050 for verification prior to making payments.
7.2.1| Registration
If a Beneficiary does not register on an appropriate Disease Management Programme, available day-to-day benefits will be applicable.
7.2.2| Oncology
The Doctor/Specialist must complete a South African Oncology Consortium (SAOC) treatment plan or write a prescription for associated oncology medication to: - Effect registration on the programme; - Facilitate the evaluation and final approval of treatment; - Ensure timely processing of cancer related claims. Fax the treatment plan to 012 679 4469. Call 0860 671 060 for specific authorisation in respect of: - Chemotherapy treatment at the Doctors/Specialists facility; - Chemotherapy treatment during hospitalisation and on an outpatient basis at the hospital; - Radiotherapy, MRI, CT and PET scans, consultations and blood tests. Oncology follow-up management programme: - Upon the treating Doctors/Specialists completion of the oncology treatment plan, Beneficiaries must register with the Schemes Oncology Case Manager on 0860 671 060 to manage follow-up treatments related to the original diagnosis. - Approved consultations and medication related to the original diagnosis will not be subject to the day-to-day benefits of the member, but to available oncology benefits.
086
7.2.4| Diabetes
Newly diagnosed diabetes: - Beneficiaries may visit the Doctor of their choice for these services; - The treating Doctor must register the condition with MediKredit on 0800 132 345.
7.2.5| HIV/AIDS
The Scheme has contracted with LifeSense Disease Management to manage the HIV/Aids Programme. Registering on the HIV/Aids Programme: - Contact LifeSense Disease Management on 0860 506 080; - Beneficiaries may visit the Doctor of their choice for the initial examination; - The treating Doctor will complete the application form in co-operation with the Beneficiary and forward the form and results of any blood test to LifeSense; - A treatment plan, submitted by the treating Doctor and based on the above information, will have to be approved by the Medical Advisor of LifeSense; - The Beneficiarys Doctor will be contacted by LifeSense and advised what medication options are available, taking in consideration the stage of the disease. Utilisation of the HIV/Aids Programme: - Once the Beneficiary is enrolled on the programme, the treating Doctor will be contacted on a regular basis by the LifeSense Case Manager; - Assistance will be provided to support and reinforce the importance of the correct utilisation of the authorised medication; - The Beneficiary will also be assisted with lifestyle adjustments and counseling. Direct enquiries related to HIV/Aids claims to the Client Service Centre on 0860 671 050.
087
7.3| MATERNITY
Pre-notification and pre-authorisation are essential in order to qualify for maternity benefits on Health Booster. Call 0860 671 050 to ensure that the pregnant Beneficiary will receive a complimentary pregnancy and birth book. Call 0860 671 060 at least one (1) week before a caesarian section or delivery (if possible), or within 48 hours after childbirth for authorisation with regard to the delivery.
7.5| PROSTHETICS
Prosthesis (an artificial body part) is an artificial replacement of an internal or external part of the body, such as a hip or knee joint, a leg, an arm, a heart valve etc. Pre-authorisation is compulsory for all external and internal prosthesis by contacting 0860 671 060, and faxing a quotation to 012 679 4471 (attention: Prosthetics).
088
7.6| OUTPATIENTS
The Beneficiarys choice
If the Beneficiary chooses to consult the outpatient facility of a hospital during hours when General Practitioners are normally available (and in some instances also for conditions not classifiable as trauma / an emergency / a PMB), it is generally an expensive choice of which the costs are not necessarily covered by any Scheme benefits.
Please note: Expenses incurred in respect of outpatient visits not covered by the Scheme, may be paid upon request from available medical savings.
089
NOTES:
08 | DENTAL BENEFITS
092
Paper claims must be submitted to the following address: DENIS Private Bag X1 CENTURY CITY 7446 (See the Benefit Structure in this Member Guide for the Dental Benefits.)
093
Crowns and Bridges: - A crown (cap) is an artificial restoration (hard cover) which is made to fit over a badly damaged or decayed tooth. - A bridge is made to replace one or more missing teeth. It is an alternative to a partial denture and usually used where there are fewer teeth to replace, or when the missing teeth are only on one side of the mouth. - Benefits for crowns are subject to pre-authorisation, where DENIS protocols apply. - All pre-authorisation requests for crown and bridge benefits must be accompanied by clinical records (treatment plans and clear X-rays of the teeth to be treated). - Clinical records must be faxed to DENIS on 0866 770 336, or e-mailed to crowns@denis.co.za. Orthodontics (braces) - Benefits for orthodontic treatment will be granted where function is impaired and are based on DENIS protocols. - Benefits will not be granted where orthodontic treatment is required for cosmetic reasons. - Benefits are limited to Beneficiaries younger than 18 years. - Only one Beneficiary per family may commence orthodontic treatment in a calendar year, except in the case of identically aged siblings. - Orthodontic re-treatment is not covered. - Orthognatic surgery (jaw correction surgery) and the associated hospital admission, is not covered. - Benefits for orthodontic treatment are granted as a percentage of MST per procedure code. The applicable procedure is paid as follows: - A deposit when the treatment starts and the balance of the tariff over the estimated treatment period. - The Member is responsible for paying the outstanding balance in respect of the deposit as well as the monthly amounts for the duration of the treatment period. - Relevant X-rays, treatment plans and clinical photographs must be faxed to DENIS on 0866 770 336, or e-mailed to ortho@denis.co.za.
094
Implants Benefit for implant treatment is only available on the Platinum option. Hospital benefits are not available for dental implants. Sinus lifts and bone augmentation procedures for implants are not covered. Relevant X-rays and treatment plans must be faxed to DENIS on 0866 770 336, or e-mailed to ortho@denis.co.za.
Periodontics - Periodontal benefit is only available to Beneficiaries who are registered on the Perio Programme. - Beneficiaries must register on the Perio Programme by submitting the CPITN score (supplied by the Dental Practitioner) together with the periodontal treatment plan to perio@denis.co.za, or alternatively faxing it to 0866 770 336. - Further clinical records may be requested to process the application. - Surgical periodontics is a Scheme exclusion.
095
NOTES:
09 | OPTICAL BENEFITS
098
(See the Benefit Structure in this Member Guide for the Optical Benefits.)
099
NOTES:
10 | EMERGENCY TRANSPORT
NOTES:
11 | CO-PAYMENTS
CO-PAYMENT
R2 500 R2 500 R2 000 R1 500 R1 500 R1 500 R1 500
PLATINUM OPTION
20% R1 000 per scan See 11.2 above 10% 10% on nonPMB conditions 10%
Chronic medicine
Chronic medicine
Category B (other)
Chronic medicine
Category B (other)
Out-of-hospital
Pathology
20%
Out-of-hospital
Threshold
10%
Dentistry
GOLD OPTION
In- or out-ofhospital In-hospital MRI and CT scans Endoscopic procedures Category A (CDL) R1 000 per scan See 11.2 above 15% Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved Payable directly to the service provider involved
Chronic medicine
Out-of-hospital Dentistry
Pathology
40%
BENEFIT
In-hospital In- or out-ofhospital In-hospital Specific procedures MRI and CT scans Endoscopic procedures Category A (CDL)
CO-PAYMENT
EXPLANATORY NOTES Payable directly to the hospital involved Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved Payable directly to the service provider involved
SILVER OPTION
See 11.1 above R1 000 per scan See 11.2 above 30%
Chronic medicine
Out-of-hospital Dentistry
Pathology
40%
EQUILIBRIUM OPTION
In-hospital In- or out-ofhospital In-hospital Specific procedures MRI and CT scans Endoscopic procedures Category A (CDL) See 11.1 above R1 000 per scan See 11.2 above 30% Payable directly to the hospital involved Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved
ESSENCE OPTION
In-hospital In- or out-ofhospital In-hospital Specific procedures MRI and CT scans Endoscopic procedures Category A (CDL) See 11.1 above R1 000 per scan See 11.2 above 30% Payable directly to the hospital involved Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved
NOTES:
12 | CLAIMS
12.1|CLAIMS PROCEDURES
The Scheme strives to make the claims procedure for Members as user-friendly as possible. In most cases, claims are submitted by service providers, i.e. Doctors, Dentists, Physiotherapists, and Pharmacists etc., on behalf of the Beneficiaries involved. The Scheme must emphasise, however, that Members should check all claim entries on every claims statement to ensure that the services charged were indeed rendered to them: - By doing this, Members will be able to notice any inaccurate claims against their benefits. - If there appears to be a problem on any claims statement, the Member must first contact the service provider involved and enquire about the claim(s) submitted. - If services were indeed not rendered, contact the Scheme and point out the discrepancies, as the Scheme would like to ensure that the Member only pays for services rendered.
- Services rendered: > The date of the service or treatment; > The nature and cost of each service or treatment item and the tariff code(s) [ICD-10 code(s)] involved; > The duration of an operation (where applicable); > The name, quantity, price and NAPPI code of each item of medication (where applicable). Take note: If the claim submitted does not contain all the necessary information, it will delay the process, thus delaying benefit payment. The Principal Member must sign and mail the original account and receipt to: KeyHealth Medical Scheme P Box 14145 .O. Lyttelton 0140 Scheme reimbursement to Members: - Any money owed to Members will be paid into their bank account, provided that the Scheme has their correct banking details; - Payments to Members are made monthly, provided that the amount payable is in excess of R50,00. If the amount payable is less than R50,00, payment will only be made once the accumulated amount reaches R50,00. Submission of claims: - Claims received by the Scheme within four (4) months of the date of treatment or service, will be processed according to Scheme Rules; - If an account is not submitted within the above mentioned period, no benefits will be payable. Please note: A receipt without the appropriate detailed account will not be considered for payment. Claims information supplied: - Processed claims will be indicated on the claims statement as follows: > Amounts paid by the Scheme, and to whom payment was made; > Refunds to Members by the Scheme (if any); > Payments owed to the Scheme by Members or any service provider (Doctor, hospital etc.); > The balance of Member benefits for the current benefit year.
- Members will also receive e-mail confirmation of claims processed (if the Scheme has the e-mail address on its database).
Non-payment of claims:
Services, material or medicine items are excluded from the Schemes benefits; Service provider is not registered with an acknowledged professional institution; Allocated benefits for a specific benefit year have been exhausted; Invalid tariff code, diagnostic or NAPPI code(s) reflected on the claim; Member or Dependant not registered on the Scheme; Benefits suspended at the time of treatment/service delivery; No authorisation was obtained for a specific service item; Claims have a service date older than four (4) months.
12.5|TRAVELLING ABROAD
To qualify for the reimbursement of out-of-hospital medical claim expenses incurred by a Beneficiary during the first ninety (90) days of travelling abroad, the Principal Member involved must inform the Scheme of the following in writing at least one (1) month in advance: - The full name and surname, and the dependant code of the Beneficiary(ies) who will be undertaking the planned foreign visit; - The name(s) of the country/countries to be visited; - The starting and end date of the visit. Please note: The Scheme may exercise sole discretion if informed within a shorter period of time. Upon receipt of the above mentioned information, the Scheme will issue a letter to the Principal Member involved, confirming the terms and conditions of medical cover during the intended foreign visit. During the foreign visit, the travelling Beneficiary(ies) will be liable for all expenses regarding out-ofhospital medical treatment. On return, or within four (4) months after the date of service, the Member applies to the Scheme for the reimbursement of the above mentioned claims by submitting the relevant account(s), together with the proof of payment. Reimbursement will be subject to the Members available day-to-day benefits and will be calculated using the foreign exchange rate applicable on the date of service and the appropriate South African tariffs for services rendered. Any elective/planned procedure performed outside of South Africa, will not be covered.
NOTES:
The Gold and Equilibrium options each provides for a medical savings account:
Note: See the Gold and Equilibrium options (chapter 3) for monthly and total medical savings amounts. - Medical savings are allocated in advance for the full benefit year (i.e. annual medical savings); any medical savings not being utilised during a specific benefit year will be carried over to the following benefit year. - The Members annual medical savings balance will be utilised first for all day-to-day medical expenses. When annual savings are exhausted, day-to-day expenses will then be covered from the applicable benefits. - After exhausting the day-to-day benefits, the available savings balance (i.e. carried forward savings) from previous years will be utilised.
Provision has been made by the Scheme for debt redemption on the medical savings account. This means that any money due to the Member will, after debt redemption, be refunded in the following instances:
Change of option: Should the selected new option not make provision for a savings account. - Resignation (1): Should a Member resign from the Scheme during the year and the Members new medical scheme does not have a savings option, the savings amount will be paid out to the Member. Should a Member resign from the Scheme during the year and the Members new medical scheme does have a savings option, the savings amount will be paid out to the new medical scheme.
- Resignation (2):
Please note: Allow up to five (5) months for the medical savings account credit balance to be refunded.
In the event of the savings amount allocated to the Member being exceeded/exhausted before 31 December, the Member will be liable to refund the amount due to the Scheme in the following instances:
- Change in KeyHealth option should the new option, selected by the Member, not make provision for a savings account; - In the event of the Member resigning from the Scheme.
The following medical expenses can also be paid from a Members medical savings account:
Co-payments; Payments of amounts where the maximum benefits were exceeded; Payments for services excluded from benefits; Payment for services rendered during waiting periods; Payment for services rendered in respect of underwriting exclusions.
A Members savings account may not be utilised to pay for any expenses regarding PMB and CDL conditions.
14 | LIST OF EXCLUSIONS
> Acupuncture; > Bio-kinetics; > Bio-stress assessments; > Colonic irrigation; > Cosmetic purposes; > DNA testing; > EBCT Computed Tomography Coronary and Heart; > Gastroplasty; > IQ tests and learning problems; > Obesity; > Reversal of sterilization; > Reversal of vasectomy; > Sclerotherapy of varicose veins. - In respect of the PMB code 902M, Infertility, the following services are excluded: > Assisted Reproductive Technology (ART) techniques, including In Vitro Fertilisation (IVF); > Gamete Intra-Fallopian Tube Transfer (GIFT); > Intra-cytoplasmic Sperm Injection (ICSI); > Zygote Intra-Fallopian Tube Transfer (ZIFT). - Charges for the following: > Ante- and post-natal exercise classes; > Appointments not kept; > Breast-feeding instructions; > Emergency unit fees, except for trauma/emergencies/PMBs and consultations leading to hospitalisation; > Mother-craft; > Telephonic consultations with Medical Practitioners; > Water-births. - Purchase or hire of the following equipment: > > > > > APS therapy machines or similar devices; Bedpans; Blood-pressure monitors; Commodes; Cushions;
> > > > > > > > > >
Health shoes, e.g. Green Cross; Humidifiers; Kidney belts; Mattresses, including Numbis mattresses; Medic Alert bands; Peak flow meters; Sheepskin; Special beds or chairs; Waterbeds; Waterproof sheets.
- The purchase of: > Growth hormones; > Household remedies or preparations of the type advertised to the public; > Medicines that are not prescribed on a written prescription of a person authorised by relevant legislation; > Mouth protectors, gold inlays, devices and materials such as floss, toothbrushes and toothpaste; > Other supplements; > Slimming preparations, appetite suppressants, food supplements and patent foods, including baby foods; > Soaps, shampoos and other topical applications, medicated or otherwise; > Sun-screening and tanning agents; > Synvisc injection; > Vitamins without a Nappi code. - General optical benefit exclusions: > > > > > > > > Contact lense solutions; Lenses with a tint exceeding 35%; Scripts less than 0.50 dioptre; Spectacle cases; Spectacle repairs; Sunglasses; The fee associated with the fitting and adjustment of contact lenses; Charges for repairs of medical appliances (for the maintenance of hearing aids, see the Benefit Structure).
Laboratory fabricated crowns on primary teeth; Lingual orthodontics; Full metal base to dentures; Metal, porcelain or resin inlays, except where such inlays form part of a bridge; Nutritional and tobacco counseling; Oral hygiene instructions; Orthodontic re-treatment; Orthognatic (jaw correction) surgery and the related hospital cost; Ozone therapy; Perio Chip; Periodontal flap surgery and tissue grafting; Polishing of restorations; Pontics on second molars; Porcelain or resin inlays, except where the inlay forms part of a bridge; Professional oral hygiene procedures in the hospital (scale, polishing and fluoride treatment); Professionally applied topical fluoride in adults; Provisional crowns; Pulp capping (direct and indirect); Resin bonding for restorations charged as a separate procedure; Root canal treatment on third molars (wisdom teeth) and primary teeth; Sinus lifts; Snoring appliances; Soft base to new dentures; Surgery and hospitalisation associated with dental implants; Three-quarter crowns (cast metal and porcelain).
NOTES:
15 | HEALTH BOOSTER
Pre-authorisation:
To qualify for any Health Booster benefit, Members must: - Contact the Client Service Centre on 0860 671 050 and obtain pre-authorisation. (Failing to do this will result in the service costs being deducted from day-to-day benefits.); - Verify the tariff code or maximum rand value with the Call Centre Consultant; - Inform the relevant service provider accordingly.
Screening tests:
One of the benefits available on the Health Booster programme is the Health Assessment. This assessment comprises the following screening tests: Body Mass Index (BMI); Blood sugar (finger prick test); Total Cholesterol (finger prick test); Blood pressure (systolic and diastolic).
Principal Members and their Adult Dependants are entitled to one Health Assessment per calendar year and must have the screening tests done at a KeyHealth DSP pharmacy. A Health Assessment (HA) form can be obtained at any KeyHealth DSP pharmacy or downloaded from KeyHealths website at www.keyhealthmedical.co.za. Results can be submitted by either the Member or the service provider, and must be faxed to 0860 111 390, for attention: Health Assessment. Results of these screening tests may require follow-up tests. For this purpose, additional blood sugar and cholesterol tests are available on the Health Booster programme. Please note: No authorisation is required for these screening tests.
Prostate specific antigen (Pathologist) Cholesterol test (Pathologist) Blood sugar test (Pathologist) HIV/AIDS test (Pathologist) Health Assessment (HA) Body mass index, Blood pressure measurement, Cholesterol test (finger prick), Blood sugar test (finger prick)
MATERNITY*
Antenatal visits (GP or Gynaecologist) & urine test (dipstick) Scans (one before the 24th week and one thereafter) Paediatrician visits Female Beneficiaries. Pre-notification of and pre-authorisation by the Scheme compulsory. Twelve (12) visits. Female Beneficiaries. Pre-notification of and pre-authorisation by the Scheme compulsory. Two (2) pregnancy scans. Baby registered on Scheme. Two (2) visits in babys 1st year.
*Pre-authorisation essential to access benefits **Only available on Platinum, Gold and Silver options
NOTES:
17 | ELECTRONIC COMMUNICATION
When choosing Option 1: - Enter the relevant KeyHealth member number and click on Validate. - Complete the following fields: surname, first name, ID number and e-mail address. Take note: If any of the completed fields do not correspond with the information on the Schemes system, registration will be unsuccessful. - The password is sent to the Member via e-mail/sms. The following message appears on the screen: Thank you for registering for web access. Your new password has been sent via e-mail/sms once you have received it, you may log in immediately. Click on Log in. The user is requested to change his/her password. Do this by entering the relevant member number and the old and new password. The following message appears on the screen: Thank you - your password was successfully changed. Click on continue. Log in by using the new password.
Forgotten Password:
In the Online Services field, click on Forgot Password. In the Login field, type in the username. Select Member. Click on Submit. The new password is received via e-mail/sms. The user is requested to change his/her password. Do this by entering the member number and the old and new password. The following message appears on the screen: Thank you - your password was successfully changed. Click on continue. The Member can now log in using the new password.
Online enquiries:
Members can view their claims history and personal information by completing their username and password in the Online Services field. The Summary information page is displayed once logged in. The following information can be viewed: - Summary a summary of the members personal details as well as a list of the last 5 claims, 6 statements and 6 contributions. - Details this page contains all of the Members personal, contact, Scheme, address, employment and banking details. - Claims all available claims submitted. - Benefits this category includes a summary of the Members maximum, used and available benefits. - Statements - all available claims statements. - Contributions a view of the Members contribution history. - Waiting periods a list of the waiting periods applicable to dependants. - Correspondence the previous correspondence between the Member and the Scheme. - Enquiry a summary of the Members enquiries. - Providers a facility where the Member can search for a provider. - Cases - the Members authorisation history. - Health Info detailed information on chronic conditions, lifestyle conditions and clinical reference. - GRP and medicine search to search for product information by using the product name.
NOTES:
DENIS ( dental) claims enquiries / Submissions e-mail claims@denis.co.za LifeSense disease management Crisis line ( Netcare 911) Chronic medication registration (to be used by providers) Optical management 0860 50 60 80
082 911
0860 671 050 membership@keyhealthmedical.co.za billing@keyhealthmedical.co.za 0860 671 050 brokersupport@keyhealthmedical.co.za www.keyhealthmedical.co.za KeyHealth Medical Scheme P Box 14145 .O. Lyttelton 0140
Postal address:
Durban
2nd floor Momentum House Cnr. Florence Nzama Street (previously Prince Alfred Street) and Bram Fisher Road (previously Ordnance Road) Old Fort Durban